This is the second and last post in the CHF case study series. In part one we looked at the MNT of our new patient. Here in part two we’re going to review how to write a nutrition assessment summary note and PES statement for this same patient.
CHF Case Study Part 2 - The Note
Before you dig into our CHF case study part 2, make sure you check out the CHF case study part one here.
Recap of our patient
You have a new 47 year old male patient who’s been admitted to the hospital with CHF exacerbation. You’ve taken a look at his chart, reviewed his labs, and spoke with him about both his medical conditions and how he’s managing those.
You’ve learned:
- Admitted with B/L +2 LE edema and a CBW of 343 lb
- PMH: CHF, DM, HTN
- Previous admission with CHF, wt of 278 lb with edema, fast food intake
- Notable labs include A1C of 7.3, up from 5.3 during previous admit
- Current meds include a diuretic, metformin, a couple blood pressure meds, baby aspirin
- Diet primarily fast food because he doesn’t cook and lives alone
You now have all the parts you need to put your nutrition assessment together. But before we do, let’s get ourselves organized with the information we currently have.
CHF Case Study Part 2: Writing the diet order
Writing diet orders can be a very straightforward task.
But what many new dietitians forget to do is include EVERY nutrition need component into their diet order.
Our patient has two big considerations that must be included in their diet order: CHF and diabetes. Additionally, you might want to consider the fact that they are overweight (this might be a factor for you).
The complete diet order for your patient with CHF and DM is: Cardiac, CCD.
If you’re wondering what’s happening with his overweight status, great question. You’ve got a couple of options.
First, a cardiac or heart healthy diet is made up of two parts – low fat and low Na.
We know that the low sodium part of his diet order is essential because not only does he have CHF, this patient also has HTN and edema, both issues that need to be managed with a reduction in sodium intake.
And to write a diet order as Cardiac, Low Na, CCD is redundant. The low Na is already implied in the cardiac diet order.
But the low fat portion of the cardiac diet might be something you want to address. This is the second thing to think about.
- Do you want your patient to have a low fat diet?
- Are you worried about his intake of saturated fat?
- Is his elevated weight a function of what he eats or is it a result of his edema that’s due to his CHF?
These are all legitimate questions. Questions that you should be asking yourself with every heart patient you see.
In this case, we know his diet is full of saturated fats because he told us about the fast food he eats. And despite the fact that he’s full of fluid which (likely) accounts for a significant amount of his weight, limiting both salt and fat to support his overall heart health is a smart play.
For more on writing great diet orders, check out the Diet Order Quick Course.
Dealing with weight change
The next thing you’re going to consider is your patient’s weight change.
With a CBW of 343 lb and a wt of 278 x 7 months ago at his previous admission, there’s some notable weight gain.
But how much?
Since his last admission, he’s gained 65 lb which is 23% of his last weight. In 7 months, this is considered significant weight change.
But there’s more.
You might remember that when you read your patient’s chart, it was noted by the last RD that when your patient was last admitted he had just gained 53 lbs over that past 3 months.
With a little quick math, we find out that 10 months ago this patient was 225 lb.
Since then (over the last 10 months), he’s gained a total of 118 lb / 52% of his UBW. That is a LOT of weight gain. It’s beyond significant. It’s concerning.
But where’s this all coming from?
It’s likely that this weight gain is primarily related to his edema which makes perfect sense with his current admission for CHF exacerbation. L/E edema (lower extremity edema) is a common symptom in CHF patients.
We’re using the word likely here because we don’t actually know for sure, so we’ll hedger our bets and say likely is related to L/E edema instead of is caused by L/E edema.
It also tracks with his reported intake of his mostly high sodium fast food diet and his questionable compliance with his medications — especially his diuretic.
So there are a lot of pieces to this puzzle that point to a combination of lifestyle and health management that likely has led to significant changes in your patient’s health.
As we keep going with our CHF case study part 2, this is a great place to start building a strong set of interventions you’ll monitor while you care for this patient.
Interventions and Education
In the part one of our CHF case study during our review of this patient’s chart, we talked about identifying the most acute issue. And there turned out to be a few options:
- CHF (reason for admission)
- Weight change (significant with noted edema)
- Diabetes (increased A1C from 5.3 to 7.3 x 3 months)
If you were on the fence about what to choose, working out this recent weight change might push you in the direction of his weight status.
You might even find yourself connecting each of these three into a complete picture.
That picture might look something like this:
The excessive sodium (and possibly caloric intake) leading to lots of water retention and changes in his blood sugar levels which then lead to significant weight increase with +2 pitting B/L LE edema that likely caused his CHF exacerbation and led to his new diagnosis of DM.
See what happened there?
We basically drafted the note and started to write your PES statement.
Writing the PES Statement
Let’s talk about the PES statement a little more.
Writing these can feel really uncomfortable because they don’t flow the way normal speech flows.
But if you can look at creating PES statements more like you’re building a bridge between your patient’s most acute issue, how you know it’s a problem, and all the ways that problem shows up in your patient’s body or life writing them can usually get a bit easier.
Looking for more help on writing PES statements? Here’s a good post for that.
But before we go any further, let’s get a few things straight.
First: Using the phrasing guidelines from the AND is incredibly useful. And many facilities you work with will require that you follow these phrasing guidelines with each PES statement you write.
When you’re asked to pull directly from this pre-prepared language, do just that.
Don’t reinvent the wheel or feel like you need to be original each time you write a new PES statement. Open up the PES Statement terminology book, find the words that fit, and then plug them into your PES statement. Or even better, keep a list of PES statements you’ve used that have worked well in the past and continue to reuse your favorites.
Second: You’ll have a much easier time writing these if you have a sense of what you want to say before you try to say it in PES statement terms.
Brainstorm through all the possible problems you see this patient having and then create a PES statement that you can both do something about (ie: the intervention you’ll implement) and that you can identify concrete evidence for (ie: symptoms).
In this case, we’ve already outlined everything we’re worried about:
PROBLEM: Excessive nutrient intake (sodium, energy, carbohydrates)
ETIOLOGY: CHF and DM
SYMPTOMS: +2 pitting B/L LE edema with significant wt gain x 10 months, increased A1C from 5.6 to 7.3
This can give us:
Excessive nutrient intake (sodium, CHO, energy) related to CHF and DM as evidenced by +2 pitting B/L LE edema with significant wt gain x 10 months, A1C of 7.3
We can also pull it apart for more specific statements:
Altered nutrient related lab values related to recently dx DM as evidenced by increase of A1C from 5.6 x 7 months ago to 7.3 on admit
Excessive nutrient intake (Na, energy) related to CHF exacerbation on admit as evidenced by B/L LE edema, reports of daily intake of fast food
Or we can come at it from the other direction and say:
Not ready for diet/lifestyle change related to denial of need to change as evidenced by mult admissions for CHF with ongoing B/L LE edema, excessive reported fast food intake
Excessive nutrient intake (CHO) related to limited food preferences as evidenced by excessive intake of fast food, concentrated and simple CHO foods
…we can do this all day. But hopefully you’re starting to see the point.
Which is there are many ways to talk about the same thing: your patient who has CHF, concerning weight gain, diabetes, and what looks like no intentions to change.
The PES statement is just a way to saying what you consider to be the most important part of your patient’s care plan. If you can write and include multiple PES statements in your note, go for it.
If you’re asked to choose just one, make it the one you’re going to write your interventions about.
Clinical Evaluation Power Pack
The Note: Writing the nutrition assessment summary
This is where part 2 of the CHF case study starts to pull everything we’ve been talking about together: the MNT and the conversation with our patient from part one of this CHF case study, and all the additional information we talked through here including the diet order and the PES statements.
Keep in mind, we’re not talking about the assessment template in the EMR you’re likely going to be required to complete for every note you write.
We’re talking about the nutrition assessment summary. It’s usually that final comment box that gives you a chance to summarize, highlight, clarify, or make note of anything you consider necessary to include in your patient’s assessment.
It’s also your chance to say whatever you need to say that wasn’t included in the template and put it on the record.
There’s no formal way to structure this part of the nutrition evaluation. Every dietitian writes their notes in a slightly different way.
Some RDs love to write in bullet points. Others use paragraphs with complete (or even incomplete) sentences. Some dietitians document every medical condition, every medication, every change in care.
Others give only the highlights (or the things they consider most important to the patient’s plan of care). And still others don’t bother re-writing anything that’s already in the assessment template and sign off with a simple “see above”.
So, how do YOU write your note?
If you have a preceptor, follow their lead. Write your note in the same style they write theirs. If you’re writing your own notes without oversight, write them however you like.
Structure of a clinical nutrition assessment note:
For a quick place to start, let’s draft a nutrition note using a very basic structure.
This example is broken up into three sections so you can see how each item we’ve talked about over this post and our previous post come into play. They include:
#1: THE BACKGROUND
- Who your patient is
- Why they were admitted and what’s their PMH (past medical history)
- Weight status (include BMI if your facility still considers it)
- Any other concerns or red flags you have (labs, upcoming procedures, medications, diet/lifestyle, readiness, high risk items)
#2: THE INTERVENTION
- The diet order you’ve recommended + any supplements you suggest
- Nutrition education you have completed
- Referrals you’ve requested and why
- PES statements (if necessary)
#3: WHAT YOU’LL MONITOR
- Nutrition education or NFPE you will provide
- Everything you’re following (weight, edema or skin integrity, intake, ONS acceptance, changes in meds, upcoming procedures)
What do each of these parts of the nutrition assessment look like for our patient?
Let’s write out what this might look like if you’re using short, concise sentences (plus a little extra information tossed in to pull it all together).
Here it is:
Pt is a 47 yo man admitted for CHF exacerbation and SOB with PMH of HTN, DM. Skin intact with +2 B/L LE edema noted on admit and NFPE. Labs on 2/10 note A1C of 7.3, elevated from 11/19 A1C of 5.6 at last admit. Meds include furosemide, metformin. Non-compliant, per pt report. Currently on IV diuretic.
Wt on admit: 343 lb, BMI: 49.2. Wt during previous admit: 278 lb. Wt gain of 65 lb / 23% x 7 months, significant. UBW x 10 months ago: 225 lb with total 118 lb / 52% wt gain, also significant.
Receiving Cardiac, CCD diet. RN reports pt has been ordering in food (pizza, fried chicken wings) and not eating provided meals.
RD provided low Na, mod CHO diet education. Encouraged avoiding fast food, eating provided meals. Discussed need for med compliance, to monitor wt and glu levels daily. Pt appeared disinterested.
Will follow edema, wt status, intake. Low Na and DM edu attempt again prior to D/C.
Excessive nutrient intake (Na, energy) related to CHF exacerbation on admit as evidenced by B/L LE edema, reports of daily intake of fast food
Altered nutrient related lab values related to recently dx DM as evidenced by increase of A1C from 5.6 x 7 months ago to 7.3 on admit.
And That’s It!
Don’t forget that there are many ways you can write a nutrition assessment summary.
What we did here is just one example and you’re likely going to see a lot of RDs (especially if you have multiple preceptors) writing their notes in a lot of different ways.
So before we wrap up this small CHF case study, here are two tips to take with you:
PRO TIP #1: When you’re starting out, cover your bases and include all relevant information in your nutrition assessment summary.
PRO TIP #2: If you have preceptors who have strong opinions about what their assessments should look like, ignore TIP 1 and follow their structure as closely as possible. Copy an assessment they’ve written before and mimic their sentence structure, the bullet points they use, and the way they organize their information.
Want even more to help in clinical?
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